Please read NOMINATING CRITERIA before completing this form.
INFORMATION ABOUT THE COMPANY OR ORGANIZATION YOU ARE NOMINATING:
Company Name:
Address:
City: State or Territory: Select AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Zip Code:
Approximately how many people are employed here?
INFORMATION ABOUT A COMPANY CONTACT PERSON: Who should be notified if the company you nominate is selected for Compassionate Employer Recognition? (someone other than you)
Title: Select Mr. Mrs. Ms. Dr. First Name: Last Name :
Contact Person's position or job title:
Contact Person's phone number (with area code and extension)
INFORMATION ABOUT YOU:
Title: Select Mr. Mrs. Ms. Dr. First Name: Last Name:
E-mail:
Phone with area code (daytime): Phone with area code (evening): How did you first hear about the Compassionate Employer Recognition Program?
Are you affiliated with a local chapter of The Compassionate Friends? Select Yes No (TCF affiliation is not a requirement.)
If “Yes,” name of TCF chapter:
Submit your personal story in 400 words or less, telling how your company met the requirements for Compassionate Employer Recognition. Please include the name(s), age(s), date(s) and cause(s) of death of your child(ren), sibling(s), or grandchild(ren) who died. Be specific in describing your company’s policies and practices (see list of criteria ) that are outstanding in their support of employees who have had a child, sibling, or grandchild die. Keep in mind that you are nominating a company or organization, not an individual or your coworkers.
As a part of its ongoing efforts to publicly encourage compassionate policies and practices in the workplace following the death of a child, sibling, or grandchild, The Compassionate Friends may publish or release to the media any or all information provided in this Compassionate Employer nomination including your contact information. Please check this box if you do not grant this permission.
Please press 'submit' only once, and then wait a few moments for a confirmation message to appear before exiting. Deadline for submission is midnight EST November 30, 2008.
